Business Process Specialist
: Job Details :

DetailsClient Name Texas Children's Hospital - HEALTHPLAN*Health Plan Job Type Local Offering IT Profession Analyst Specialty IT Business Analyst Job ID 15336116 Job Title Business Process Specialist Weekly Pay $180.0 Shift DetailsShift 5x8 Days Scheduled Hours 40 Job Order DetailsStart Date 11/18/2024 End Date 02/15/2025 Duration 13 Week(s) Job Description Medical Coder Pride Health is hiring a Medical Coder to support our client's medical facility based in California. This is a 12-week contract with the possibility of an extension with competitive pay and benefits and a great way to start working with a top-tier healthcare organization Location - Houston, TX Length of Assignment - 12 Weeks (Possibility of Extension) Pay Range - $35 to $40/hr. Shift and Schedule - Monday-Friday 8 am to 5 pm. Job Summary: We seek a Certified Medical Coder with expertise in medical coding, claims analysis, and reimbursement policies to join the team. This role requires a detail-oriented professional who is skilled in data analysis and familiar with healthcare reimbursement processes, specifically within Medicaid and Medicare programs. The successful candidate will analyze large claims data sets, review provider billing patterns, ensure compliance with coding regulations, and support the development and enhancement of reimbursement policies. You will also collaborate with cross-functional teams, conduct root cause analysis, and provide leadership and guidance on coding practices to ensure accurate and timely claims processing. Key Responsibilities: •Medical Coding & Claims Analysis: Review and analyze medical claims for compliance with coding rules and regulations, including HCFA/UB-04 claims management, CMS guidelines, Correct Coding Initiative (CCI), Medically Unlikely Edits (MUEs), and other industry standard coding policies. •Policy Development & Compliance: Develop customized prospective medical coding and reimbursement policies, configure coding edits, and ensure alignment with current regulations, industry standards, and CMS guidelines. •Data Analysis & Reporting: Utilize large claims data sets to provide analysis on provider billing patterns and identify trends or discrepancies. Generate reports on coding compliance and make recommendations for improvements based on new or revised coding edits. •Collaboration & Leadership: Collaborate with business partners, system configuration teams, and leadership to discuss findings, report outcomes, and propose corrective actions. Serve as a Subject Matter Expert (SME) on coding guidelines and their impact on provider reimbursement. •Root Cause Analysis: Conduct root cause analysis on claims issues and assess the potential financial impact of regulatory changes. Provide actionable insights for continuous improvement. •System Configuration & Testing: Work with system and data configuration teams to ensure accurate implementation of coding edits. Participate in user acceptance testing (UAT) and post-production reviews to identify and resolve any issues. •Reimbursement Policy Library Management: Maintain and update the reimbursement policy library to reflect the latest coding standards and guidelines. •Regulatory Compliance: Stay current with federal and state regulations regarding Medicaid and Medicare billing practices, coding changes, and reimbursement methodologies. •Training & Education: Provide guidance and training internal teams on coding practices, compliance issues, and changes in reimbursement policies. Required Qualifications: Education: •Bachelor's degree in business, Health Care Administration, Public Health, Nursing, MIS, or a related field. •Master's degree in business, Health Care Administration, Public Health, Nursing, MIS, or a related field may substitute for 2 years of required experience. Experience: •Minimum of 2 years of experience in a managed care organization (MCO) or a related healthcare organization. •Direct and relevant experience with HCFA/UB-04 claims management, coding rules and guidelines, and evaluating claim outcome results. •Experience in analyzing and interpreting claims data, applying CMS guidelines, CCI, MUEs, and modifier-to-procedure validation. •Proficient in Microsoft Excel (pivot tables, VLOOKUP, SUMIF, and other advanced functions). Certifications: Certified Professional Coder (CPC), Certified Inpatient Coder (CIC), or Certified Professional Medical Auditor (CPMA) is required. Knowledge & Skills: •Strong understanding of healthcare reimbursement methodologies, particularly Medicaid and Medicare. •Familiarity with Tapestry or similar claims management systems (preferred). •Excellent written and verbal communication skills, with the ability to interact effectively with individuals at all levels of the organization. •Strong problem-solving skills, attention to detail, and ability to manage multiple complex tasks simultaneously. •Ability to present and explain technical findings to leadership and other stakeholders. Desired Qualifications: •Experience in working with or within reimbursement configuration departments. •Familiarity with healthcare industry regulations, especially related to payment integrity, compliance, and medical coding standards. Benefits Pride Global offers eligible employee's comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors. Equal Opportunity Employer As a certified minority-owned business, Pride Global and its affiliates - including Russell Tobin, Pride Health, and Pride Now - are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, disability, age, veteran status, or other characteristics Client DetailsAddress 6330 West Loop South, HEALTHPLAN*Health Plan - WLS City Bellaire State TX Zip Code 77401 Job Board Disclaimer Pride Global and its entities offers eligible employee's comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto ,home insurance, pet insurance, and employee discounts with preferred vendors.